CLOSING
THE
BLACK-WHITE GAP
In the United States, Black infants have significantly worse birth outcomes than White infants.
Over the past decades, public health efforts to
address these disparities have focused primarily
on increasing access to prenatal care, however,
this has not led to closing the gap in birth
outcomes. We propose a 12-point plan to reduce
Black-White disparities in birth outcomes using a
life-course approach. The first four points (increase access to interconception care, preconception care, quality prenatal care, and healthcare throughout the life course) address the
needs of African American women for quality
healthcare across the lifespan. The next four
points (strengthen father involvement, systems
integration, reproductive social capital, and
community building) go beyond individual-level
interventions to address enhancing family and
community systems that may influence the health
of pregnant women, families, and communities.
The last four points (close the education gap,
reduce poverty, support working mothers, and
undo racism) move beyond the biomedical
model to address the social and economic
inequities that underlie much of health disparities. Closing the Black-White gap in birth
outcomes requires a life course approach which
addresses both early life disadvantages and
cumulative allostatic load over the life course.
(Ethn Dis. 2010;20 [Suppl 2]:s2-62–s2-76)
Key Words: Life Course Perspective, Disparities, Birth Outcomes, Programming, Allostatic
Load, Preconception Care, Prenatal Care,
Quality, Father Involvement, Systems Integration, Social Capital, Maternity Leave, Childcare, Racism
From the Departments of Obstetrics
and Gynecology (MCL) and Pediatrics (NH),
David Geffen School of Medicine at UCLA;
the Department of Community Health
Sciences and the Center for Healthier
Children, Families and Communities, UCLA
School of Public Health (MCL, NH) and
Department of Maternal and Child Health,
Boston University School of Public Health
(MK) and Department of Maternal and
Child Health, University of North Carolina
at Chapel Hill (VH) and Healthy African
American Families, Los Angeles, CA (LJ) and
UCLA School of Nursing (KW).
Address correspondence or reprint request to Michael C. Lu, MD, MPH; Department of Community Health Sciences; UCLA
School of Public Health; Box 951772; Los
Angeles, CA; 90095-1772; 310-825-5297;
310-794-1805 (fax); mclu@ucla.edu
S2-62
IN
BIRTH OUTCOMES: A LIFE-COURSE APPROACH
Michael C. Lu, MD, MPH; Milton Kotelchuck, PhD, MPH;
Vijaya Hogan, DrPH; Loretta Jones, MA;
Kynna Wright, PhD, MPH; Neal Halfon, MD, MPH
In the United States, Black infants
are more than twice as likely to die
within the first year of life as a White
infant, a gap that has not substantially
closed in over half a century.1,2 A
significant portion of the disparity in
infant mortality is attributable to the
near two-fold increased rates of low
birth weight (LBW) and preterm births,
and the near three-fold increased rates
of very low birth weight (VLBW) and
very preterm births, among Black
infants.3
The cause of racial disparities remains largely unexplained. Most studies
focus on differential exposures to risk
and protective factors during pregnancy,
such as maternal behaviors,4 prenatal
care utilization,5 psychosocial stress6 or
infections.7 These factors however do
not adequately account for the racial
gap in birth outcomes.8,9 Lu and
Halfon10 recently proposed an alternative approach to examining racial-ethnic
disparities in birth outcomes using the
life course perspective. The life course
perspective conceptualizes birth outcomes as the end product of not only
the nine months of pregnancy but the
entire life course of the mother before
the pregnancy. Disparities in birth outcomes, therefore, are the consequences
of both differential exposures during
pregnancy and differential developmental trajectories across the life span.
The life course perspective synthesizes two longitudinal models: an early
programming model and a cumulative
pathways model.11,12 The early programming model posits that early life
exposures influence future reproductive
potential. For example, perinatal stress
is associated with high stress reactivity
that persists into adulthood.13–15,17,18
This, in turn, may be related to feedEthnicity & Disease, Volume 20, Winter 2010
back resistance from altered expression
of glucocorticoid receptors in the developing brain.16 Exposure to stress hormones during sensitive periods of immune maturation in early life may also
alter immune function, leading to
increased susceptibility to infectious or
inflammatory diseases later in life.19
Hypothetically, maternal stress during
pregnancy could prime fetal neuroendocrine and immune systems with stress
hormones, leading to higher stress
reactivity and immune-inflammatory
dysregulation that could increase a
female offspring’s vulnerability for preterm labor and LBW later in life. Thus
the increased risk of African American
women to preterm birth and LBW may
be traced to greater exposures to stress
hormones during pregnancy, early life,
and possibly even in utero.
The cumulative pathways model
proposes that chronic accommodation
to stress results in wear and tear, or
allostatic load,20 on the body’s adaptive
systems, leading to declining health and
function over time. Animals and humans subjected to chronic and repeated
stress have elevated basal cortisol levels
and exaggerated hypothalamic-pituitary-adrenal (HPA) response to natural
or experimental stressors.21,22 This HPA
hyperactivity may reflect the inability of
a worn-out system for self-regulation,
possibly due to loss of feedback inhibition via down-regulation of glucocorticoid receptors in the brain.21 Chronically elevated cortisol levels may also
lead to immune suppression and immune-inflammatory dysregulation. 23
HPA hyperactivity and immune-inflammatory dysregulation are two of several
possible mechanisms by which chronic
and repeated stress over the life course
may lead to increased vulnerability to
preterm labor caused by stress or
CLOSING GAP IN BIRTH OUTCOMES - Lu et al
Table 1. A 12-point plan to close the Black-White gap in birth outcomes: A lifecourse approach
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Provide interconception care to women with prior adverse pregnancy outcomes
Increase access to preconception care to African American women
Improve the quality of prenatal care
Expand healthcare access over the life course
Strengthen father involvement in African American families
Enhance coordination and integration of family support services
Create reproductive social capital in African American communities
Invest in community building and urban renewal
Close the education gap
Reduce poverty among African American families
Support working mothers and families
Undo racism
infection. This model suggests the
increased risk of African American
women for preterm birth and LBW
may be related to increased exposures to
stress during pregnancy and possibly to
increased weathering of stress over their
life course, resulting in greater allostatic
load which may already be present
before pregnancy.24
The life course perspective suggests
that closing the Black-White gap in
birth outcomes requires more than
improving access to prenatal care for
African American women. From this
perspective, it is not surprising that our
national and state policies over the past
two decades have not been more
successful in closing the racial gap in
birth outcomes. To expect prenatal care,
in less than nine months, to reverse the
lifelong, cumulative impact of social
inequality on the health of African
American mothers, may be expecting
too much of prenatal care. Closing the
racial gap in birth outcomes requires a
life course approach, addressing both
early life disadvantages and cumulative
allostatic load.
The purpose of this commentary is
to propose this life course approach. We
recognize we do not know all life course
factors related to the disparities nor have
all the answers to address them, but we
believe we must do something. We
present a platform of what we can do
now – a 12-point plan building on
previous work25 and a literature search
for promising strategies. The 12 points
are summarized in Table 1. The goals
are to: 1) improve healthcare for African
American women; 2) strengthen African
American families and communities;
and 3) address social and economic
inequities that create a disproportionate
toll on the health of African American
women over their life course. This plan
departs from current approaches to
create a new paradigm for closing the
racial/ethnic gap in birth outcomes.
First, it goes beyond prenatal care and
addresses healthcare needs of African
American women from preconception
to interconception and across the life
course. Second, it goes beyond individual-level interventions and addresses
family and community systems. Third,
it goes beyond the medical model and
addresses social and economic inequities
that underlie much of health disparities.
While a life course approach is needed
to address health disparities in any
community, we focus our discussion
on its application in the African American community given the disproportionate burden of infant mortality and
other poor maternal and child health
(MCH) outcomes borne by that community.
IMPROVING HEALTHCARE
FOR AFRICAN AMERICAN
WOMEN
While health care alone cannot close
the gap, it is a good place to start.
Ethnicity & Disease, Volume 20, Winter 2010
Health care has a vital role, especially if
provided over the woman’s life course,
and not only during pregnancy. The
right health care can promote positive
development in early life and reduce
cumulative allostatic load over the life
course. Expanding access to interconception care, preconception care, quality
prenatal care, and health care over the
life course are important strategies in
closing the racial gap in birth outcomes.
Provide Interconception Care
for Women with Prior Adverse
Pregnancy Outcomes
Interconception care allows for continuity of health care from one pregnancy to the next.26 Ideally interconception care should be provided to all
women between pregnancies as part of
comprehensive women’s health care.
However, given resource constraints, it
could be initially targeted to women
with prior adverse pregnancy outcomes
(ie, preterm birth, LBW, intrauterine
growth restriction, fetal or infant death).
Women with a poor pregnancy outcome are at substantial risk for having
another poor pregnancy outcome.27,28
Many biobehavioral risk factors for
preterm birth are carried from one
pregnancy to the next. The interconception period offers an important window
of opportunity for addressing these risk
factors and optimizing women’s health
before their next pregnancy. However,
present access to health care in the
interconception period is limited for
many African American women, particularly low-income women whose
pregnancy-related Medicaid coverage
generally terminates at sixty days postpartum.26 African American women
would benefit more from interconception
programs given their greater risk from
prior adverse pregnancy outcomes and
less access to health care during the
interconception period.
There have been several interconception care demonstration projects,
most notably programs in Atlanta,
Denver, Jacksonville, Philadelphia, and
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CLOSING GAP IN BIRTH OUTCOMES - Lu et al
several Healthy Start sites.29,30 Since
2005, Healthy Start programs are
required to include an interconception
care component. The interconception
care program in Denver was shown to
reduce the risk of recurrent LBW births
by one-third, though this finding must
be interpreted with caution because of
potential selection bias.
Most interconception programs
consist of four components: risk assessment, health promotion, medical and
psychosocial interventions, and outreach and case management. The initial
risk assessment should be comprehensive to detect factors associated with
adverse birth outcomes, including expert review of medical records. Risk
assessment should be on-going throughout the interconception period, and
help guide development of an individualized care plan for health promotion
and medical/psychosocial interventions.
Core services should include family
planning,31,32 screening for maternal
depression and intimate partner violence, assessing social support for the
pregnant woman, smoking cessation
and substance treatment programs,
physical activity and nutritional education and intervention, management of
chronic diseases, and education on
back-to-sleep and parenting skills. The
individualized interconception care plan
should also address known biobehavioral pathways to a particular outcome.
For example, in preventing recurrent
preterm birth, interventions should
consider neuroendocrine, infectious-inflammatory, vascular, and behavioral
pathways to recurrence.33 Potential
strategies may include those that reduce
chronic stress and increase social support, 34,35 decrease chronic infections, 36,37 restore immune allostasis,38,39 address vascular causes40 and
improve health-promoting behaviors.41
Arguably, many interventions could be
adopted on the basis of promoting
women’s health alone, even in the
absence of data on their effectiveness
in preventing recurrence of adverse birth
S2-64
outcomes.42,43 The program should be
multi-level and include communitylevel interventions promoting interconception care.
Interconception care programs
could be funded through a Medicaid
waiver, expansion of State Children’s
Health Insurance Program (SCHIP) to
cover adult family members, increased
scope of services for Title X or state
family planning programs, or direct
funding from Title V or non-governmental sources. While more work is
needed to explore financing, content,
and cost-benefit of interconception care,
it is an important first step to move us
beyond current focus on prenatal care
and toward a more expanded, longitudinally-integrated approach for addressing disparities in birth outcomes.
Increase Access to Preconception
Care for African American
Women
As with interconception care, the
goal of preconception care is to restore
allostasis and optimize women’s health
prior to pregnancy. Many pathophysiologic processes leading to adverse pregnancy outcomes may have their onset
early in pregnancy. For example, an
infection associated with preterm delivery may be present in the urogenital
tract before pregnancy.43 If it is not
cleared by midgestation, preterm labor
or preterm premature rupture of membranes may ensue. Screening for and
treating bacterial vaginosis (BV) with
antibiotics during pregnancy may be less
effective in preventing preterm birth.
This may partially explain the disappointing results of several antibiotic
trials in pregnancy.44,45 Even if the
infection is treated, it may be too late to
stop immune-inflammatory processes.
Preconception care provides an important opportunity to treat ongoing infection and restore immune allostasis.
Most models of preconception care
were developed with the primary aim
of preventing congenital anomalies.46
Further research is needed to develop
Ethnicity & Disease, Volume 20, Winter 2010
preconceptional strategies for preventing preterm births and LBW by addressing stress reduction, social support,
immune response, chronic infections,
inflammation, and behavioral and nutritional risk factors.
Recruiting women into preconception care programs without a specific
intervenable event and a targetable time
period may be difficult.47 Targeting
preconception care to couples actively
planning a pregnancy will miss about
half of all live births unintended at
conception.48 Therefore, preconceptional health promotion and disease
prevention should be integrated into a
continuum of care throughout the life
cycle.48 Every routine visit by any
woman who may become pregnant at
some time should be viewed as an
opportunity to provide preconception
care.49 Public health efforts should
focus on increasing access to, setting
standards for, and assuring quality of
preconception care. Since Medicaid
covers about half (51%) of African
Americans with family incomes below
the poverty level and 17% of those
between 100% and 199% of the
poverty level (near-poor),50 expanding
Medicaid to cover preconception care
could substantially increase access for
low-income African American families.
Another 15% of the poor and nearly
half (48%) of the near-poor African
Americans have job-based insurance;50
mandating or subsidizing job-based
health insurance coverage of preconception care could further increase access.
These expansions will still leave out
three in ten African American women
who are uninsured.50 Strategies must
also consider how to provide preconceptional education and services to adolescents (eg, school-based clinics or family
planning programs). The surest way to
increase access to preconception care is
through a national health insurance
program which provides coverage for
comprehensive women’s health care.
More work is still needed to explore
the financing, standards, and quality
CLOSING GAP IN BIRTH OUTCOMES - Lu et al
assurance for preconception care. In
2005, the Centers for Disease Control
and Prevention (CDC) issued recommendations to improve preconception
health and health care.51 These recommendations begin to lay out a roadmap
toward universal preconception care in
the United States. We believe ‘‘preconception care, focusing on women’s
overall health … prior to pregnancy,
will serve as a key component of the
next wave of low-birthweight and infant
mortality reduction strategies – and may
provide increased savings beyond those
experienced from prenatal care
alone.’’52 We join the call for this
nation to make ‘‘a commitment to
advance preconceptional services to a
similar extent as it has prenatal care.’’52
Improve the Quality of Prenatal
Care for African American
Women
The life course perspective sees
prenatal care as vitally important, both
as part of the continuum of health care
for the mother, and as the starting point
for the child’s developmental trajectory.
It recognizes the potential contributions
of prenatal care to optimal developmental programming of the baby’s vital
organs and systems. For example, poor
glycemic control in mothers with pregestational or gestational diabetes has
been linked to suboptimal fetal development of pancreatic beta-cell structures and functions and greater adult
susceptibility for insulin resistance and
diabetes.53 By promoting optimal antenatal glycemic control, prenatal care
may reduce intergenerational transmission of insulin resistance and diabetes.
Thus prenatal care has an important
role in closing the racial gap in not only
birth outcomes but possibly in health
and developmental outcomes over the
life course and across generations.
Over the past decade, the racial gap
in access to prenatal care has been
closing. Today nearly 95% of African
American women access prenatal care at
some point during pregnancy; three in
four do so in the first trimester.3
However, little has been done to close
the racial gap in the quality of prenatal
care. More than one-third of US
women reported receiving no advice
on tobacco or other substance use
during prenatal care.54 Black women
were significantly less likely than White
women to receive health behavior advice
from prenatal care providers, and women who received insufficient health
behavior advice were at higher risk of
delivering a LBW infant.54,55 Other
studies have documented similar racial
gaps in the quality of prenatal care.56
Quality is also determined by the
availability of services. Many ancillary
services (eg, childbirth education classes,
mental health or periodontal services,
breastfeeding support), are often unavailable or in short supply in underresourced African American communities.
One promising strategy for improving prenatal care quality is the Breakthrough Series (BTS), which uses a
collaborative learning model and rapid
Plan-Do-Study-Act (PDSA) cycles to
bring about quality improvement.57
The effectiveness of the BTS for quality
improvement has been demonstrated in
other areas of healthcare,66,67 and is
now being applied to prenatal care
through on-going collaboratives in Vermont and Los Angeles.68 The BTS takes
established, but not routinely implemented, clinical standards or best practices and brings together healthcare
providers to examine care processes
and make them better through rapid
cycles of change. Already established
clinical standards related to prenatal
care include screening and referral for
smoking,58 substance use,59 poor nutrition,60 intimate partner violence,61 and
maternal depression,62 just to name a
few. More research is needed to evaluate
whether other practices, such as infection screening and treatment (eg,
asymptomatic BV,63 periodontal disease37) or progesterone treatment64,65
can be recommended as clinical stanEthnicity & Disease, Volume 20, Winter 2010
dards. There is also a need to reconvene
a national consensus meeting on the
content of prenatal care, as none has
been convened since the mid-1980s.69
Assuring availability of important ancillary services is another important step in
prenatal care quality improvement.
Expand Healthcare Access over
the Life Course for African
American Women
Closing the Black-White gap in
birth outcomes requires improving access to quality health care over the life
course. Approximately one in five
African American children are uninsured, and one in four non-elderly
African American women are uninsured, rates nearly twice those for nonHispanic whites.50 Uninsured African
Americans are more than three times as
likely to be without a usual source of
care, and more than twice as likely not
to have met minimum standards for
physician visits, compared to those with
private or Medicaid coverage.50 Among
uninsured African Americans, one in
ten aged 0 to 5 years, one in five aged 6
to 17, and one in five women in fair or
poor health fail to meet minimum
standards for regular check-ups.50 The
lack of access to preventive and primary
care among the uninsured can cause
delayed diagnosis and treatment of
chronic diseases (eg, hypertension) or
maintenance of risk behaviors (eg,
cigarette smoking, poor nutrition), resulting in a greater cumulative physiologic toll over the life course and
increased biobehavioral vulnerability to
adverse perinatal outcomes.
Low family incomes are the primary
reason for the relative lack of health
insurance coverage among African
Americans.50 Medicaid covers only half
of African Americans in poor households, and only 17% of African Americans in near-poor households. Only
16% of African American women ages
18 to 64 receive Medicaid despite that
nearly one-fourth (23%) are poor and
nearly one-half (45%) are near poor.
S2-65
CLOSING GAP IN BIRTH OUTCOMES - Lu et al
Thus expanding Medicaid coverage for
poor and near-poor families can be an
important strategy for increasing healthcare access for African American women. States have many options, though
limited funding, to expand Title XIX
Medicaid coverage for uninsured populations.50 The family coverage option of
section 1931 of the Social Security Act
allows states considerable flexibility in
setting income eligibility for Medicaid
to cover parents and children above the
federal poverty level. Section 1115
allows states to obtain federal waivers
to restructure Medicaid programs and
enable uninsured adults without children, and families above the current
income eligibility limits, to buy into the
program on a sliding scale. African
Americans are more likely to work in
settings (ie, large businesses) that provide access to employment-based health
insurance, but they are less likely than
Whites in comparable settings to receive
such coverage.50 An employer mandate
to cover all employees and their dependents would substantially close the racial
gap in job-based health insurance coverage. But neither Medicaid expansion
nor an employer mandate will provide
universal coverage, leaving a large
number of African American women
and families still uninsured or underinsured. We join the call for a national
health insurance program to provide
universal, comprehensive coverage to all
Americans over their entire lifespan.70
Healthcare access is not all about
health insurance. In an increasingly
diverse nation, there is also need for
increased diversity and linguistic and
cultural competence in the health workforce.71–73 Cultural competency and
respect for diversity are learned. The
work of healthcare providers increasingly
requires communication and interaction
with people of diverse backgrounds. The
training ground for acquiring the skills of
an effective practitioner in a diverse
society begins in medical, nursing, and
other allied health schools, universities,
or earlier. Increased diversity in the
S2-66
faculty and student body of these schools
would provide the level of interaction
with diversity necessary to create a
culturally competent health workforce.74
We support programs and opportunities
that increase the diversity of the medical
workforce.
STRENGTHENING AFRICAN
AMERICAN FAMILIES AND
COMMUNITIES
Families and communities can be
important sources of support and resiliency, but also causes of stress and
vulnerability, for pregnant women and
their children. Being the head of a
single-parent household with little or no
father involvement, dealing with fragmented systems to get unfriendly family
support services, living in neighborhoods where neighbors do not know
or look after one another, and residing
in communities with concentrated poverty, high crime rate, poor housing, no
parks, limited bus services, and inadequate day care add to the daily wear and
tear many African American mothers
experience. Closing the racial gap in
birth outcomes will take more than
improving healthcare; it requires
strengthening father involvement, enhancing service coordination and systems integration, creating reproductive
social capital, and investing in community building and urban renewal. In
short, it will take strengthening family
and community support for African
American mothers.
Strengthen Father Involvement
in African American Families
Fathers can be a vital source of
support for the mother and resiliency
for the child. Yet today many African
American men do not stay involved in
the pregnancies they caused, nor in
raising the children from these pregnancies. In 2006, more than 70% of African
American infants were born to unmarried mothers, up from 22% in 1960.3
Ethnicity & Disease, Volume 20, Winter 2010
Among poor African American infants,
approximately one-third are born into
single-mother families with little or no
father involvement.75 More than half
(53%) are born into so-called fragile
families. 75 While many unmarried
fathers may be actively involved at birth,
over time their involvement declines.
Today nearly half (49%) of all poor
African American children grow up in
single-mother families with little or no
father involvement.75 While father absence is not unique to the African
American community, its toll on African
American women and children is especially high. Studies have shown that,
controlling for parental education, income and other confounding factors,
children growing up in father-absent
families are at greater risk for various
educational or behavioral problems and
poorer developmental outcomes.80
Father involvement is discussed in
detail elsewhere in this issue.76 To
strengthen father involvement in African American families, both an ecological approach81 and a life course
perspective10 are needed. An ecological
approach addresses barriers to father
involvement at multiple levels. At the
individual level, fathers need educational programs, employment-related
services, and legal and social services.82
At the interpersonal level, efforts should
focus on improving the relationships
between African American men and
women, including marriage counseling,
family therapy or skills training in
communication and conflict resolution.
At the neighborhood and community
level, interventions must address high
rates of unemployment and incarceration among African American. At the
institutional level, many African American churches, universities, and media
have taken leadership roles in the
fatherhood movement, but more need
to do so.78 These institutions can help
promote changes in norms, values and
expectations that support marriage and
strengthen the father-child bond.
Healthcare providers also have an im-
CLOSING GAP IN BIRTH OUTCOMES - Lu et al
portant role in supporting fathers’
involvement in their family’s healthcare.83
At the policy level, public policy
needs to support the ability of fragile
families to stay together. Current policies often do the opposite. Policy
reforms are needed to remove disincentives for father involvement in
Temporary Assistance for Needy Families (TANF) (ie, eliminating the distinction between single- and two-parent
families for eligibility), Earned Income
Tax Credit (EITC) (ie. allowing a
second-earner deduction), and child
support (eg, establishing amnesty programs or extending TANF, EITC, and
other support services to non-custodial
fathers who pay child support).84,85
Most importantly, increasing economic
opportunities by promoting full and
consistent employment, job skills training and retraining, fair trade, and
unionization will help restore Black
fathers to Black families.77–79
The life course perspective recognizes that fathers have a life history of
their own. Their involvement in their
children’s lives is determined in part by
their own life experiences, including
their own father’s involvement in their
childhood.76 The capacity to support
and nurture needs to be cultivated over
their life course. Thus, closing the
Black-White gap in adverse birth outcomes requires strengthening father
involvement through a multi-level approach addressing individual-level (eg,
skills), interpersonal (eg, gender relations), neighborhood and community
(eg, unemployment, incarceration), institutional (eg, cultural norms, racial
stratification), public policy (eg, tax,
welfare, and child support), and other
life course factors.
Enhance Systems Coordination
and Integration for Family
Support Services
Presently there is a great deal of
fragmentation in the delivery system for
family support services. Enhancing ser-
vice coordination and systems integration may help reduce stress and increase
support for pregnant and parenting
women and their families. Women
needing multiple services often have to
take time off from work on different
days, arrange child care, find transportation to different appointment locations, fill out duplicative records, and
still may not receive needed services
because of missing referral paperwork or
provider miscommunication. Fragmentation in service delivery deters access to
care, particularly for low-income women with other competing needs. These
women need help with service coordination. Programs like the Nurse Family
Partnership86 or Black Infant Health
program87 in California have demonstrated some success in providing service
coordination for low-income pregnant
and parenting women through case
management and home visitation.
Another possible strategy for service
coordination and integration is a family
resource center with one-stop shopping,
which delivers a comprehensive, integrated portfolio of pregnancy and
family support services at a single
location or under one organizational
umbrella.88 The Hope Street Family
Center in Los Angeles and the Developing Families Center in District of
Columbia offer promising models.
Hope Street provides a full array of
services, including prenatal care, wellbaby care, primary care, on-site child
care, Early Head Start, child development and family literacy programs.
Where it is not possible for all services
to occur under one roof, different
providers can work to coordinate services, conduct follow-up upon referrals,
reduce duplication, and create a virtual
family resource center.
To develop a comprehensive, family
resource center, a community must be
able to knit together different categorical programs into an integrated funding mechanism. An on-going policy
experiment, the Monroe County (New
York) Child and Family Health InitiaEthnicity & Disease, Volume 20, Winter 2010
tive, works to create an integrated
service delivery system driven by family
needs rather than categorical funding
requirements.88 This initiative blends
funds from six different funding streams
into one master contract with one set of
reporting mechanisms and a greater
focus on results. Integration of funding
streams may help promote service
integration and multidisciplinary,
multi-level, and multisector collaboration. Evaluation of the Monroe County
Initiative is currently ongoing.
Create Reproductive Social
Capital in African American
Communities
In recent years, social capital has
emerged as a possible protective factor
against the detrimental effects of stress
on health. Social capital describes the
degree of social connectedness within a
community or society and refers to
features of social organization (eg, networks, norms, social trust) that facilitate
coordination and cooperation for mutual benefit.89,90 Social capital is characterized by: 1) the existence of community networks; 2) civic engagement;
3) local identity and a sense of solidarity
and equity with other community
members; and 4) trust and reciprocal
help and support. Several studies link
social capital to health disparities,
including disparities in infant mortality.90
A related concept is reproductive
social capital – defined as features of
social organization that facilitate coordination and cooperation to promote
reproductive health within a community.91 With respect to pregnancy, it
describes the degree of social connectedness of the pregnant woman to her
community. Presently little is known
about how to build reproductive social
capital in a community;92 this issue of
Ethnicity & Disease provides an instructive example from a community-based
program in Los Angeles.91 One Hundred Intentional Acts of Kindness
toward a Pregnant Woman was created
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CLOSING GAP IN BIRTH OUTCOMES - Lu et al
by Healthy African American Families
to increase reproductive social capital
for pregnant women. In local focus
groups, pregnant or postpartum women
were asked to identify specific actions
that families, friends, and strangers
could take to help make their pregnancies better. From families and friends,
women primarily wanted acts demonstrating emotional and instrumental
support; from strangers they wanted
acts of respect for personal space and
common courtesy. Based on their
responses, One Hundred Intentional
Acts of Kindness toward a Pregnant
Woman was created, printed on fans,
and distributed in churches, barber
shops, nail salons, and other locations.
While the effectiveness of the One
Hundred Acts program is currently
being evaluated, it provides an example
of how a community can create reproductive social capital to increase daily
social support for pregnant women. The
program took on a life course approach
as One Hundred Intentional Acts of
Kindness toward a New Mother and
One Hundred Intentional Acts of
Kindness to Yourself (for self-support)
were also developed. While these activities do not address structural inequities,
they exemplify things a community
(under the leadership of communityor faith-based organizations) can readily
do to support pregnant and parenting
women and families.
Invest in Community Building
and Urban Renewal
As much as it takes a village to raise
a child, it takes a community to grow a
healthy baby. A growing body of
evidence suggests that neighborhood or
community characteristics may be important determinants of birth outcomes.
Increased risk of VLBW births occurred
among African American women rating
their neighborhoods unfavorably in
eight characteristics: police protection,
property protection, personal safety,
friendliness, municipal service delivery,
cleanliness, quietness, and schools.93
S2-68
Urban African-American women were
more likely to deliver LBW infants
when they lived in socioeconomically
disadvantaged area, regardless of individual level poverty and other risk
factors.94
Several potential pathways linking
neighborhood and community characteristics to adverse birth outcomes have
been suggested. First, because of the
history of residential segregation, African Americans are more likely to live in
concentrated poverty neighborhoods
where daily life is more stressful.95
Second, these neighborhoods are more
likely to be located near freeways,
industrial parks, and toxic waste dumps,
exposing residents to greater amounts of
pollutants, which increase the risks of
adverse birth outcomes.96–100 Third,
these neighborhoods are more likely to
include a higher proportion of individuals with maladaptive coping behaviors, including violence, drug and
alcohol abuse, and smoking. Women
living in concentrated poverty neighborhoods are, therefore, more likely to be
exposed to these negative influences.
Fourth, there is less access to places to
exercise safely or to purchase fresh fruits
and vegetables. In many disadvantaged
communities, there are more liquor
stores than grocery stores, and more
fast food restaurants than healthy restaurants. The typical cost of food is
approximately 15%–20% higher in
poor neighborhoods than in affluent
neighborhoods, while the quality of
food available is poorer.101 Fifth, these
neighborhoods are typically underserved
by healthcare and social service providers.102
As long as large numbers of African
American women grow up and reside in
neighborhoods and communities that
put them at early-life disadvantages and
under greater cumulative allostatic load,
racial disparities in birth outcomes will
likely persist, even with the best health
care. Closing the Black-White gap in
birth outcomes requires building stronger and healthier communities that
Ethnicity & Disease, Volume 20, Winter 2010
promote not only healthy pregnancy,
but the life course health development
of women and families. Because over
half (52%) of all African Americans live
in a central city within a metropolitan
area, and nearly 90% live in a metropolitan area, a good starting place is
America’s cities.103 Community building must begin with economic development; it is difficult to build and sustain
a healthy, vibrant community when
over half of its African American male
residents are jobless or underemployed,
as in many large cities. Community
building also requires infrastructure
development, such as affordable and
decent housing, good schools, safe
neighborhood, accessible parks and
recreation, clean air and water, and
competent healthcare. The Smart
Growth 104 and New Urbanism 105
movements provide innovative models
of urban development that could also
promote population health. And while
MCH advocates are not directly in the
business of building housing, schools or
parks, they need to partner with those
who can.
Community building requires political development. This involves building community networks and mobilizing civic participation, two important
dimensions of social capital. A promising model is the Healthy Births Learning Collaboratives (HBLCs) of the Los
Angeles County Best Babies Network.
An HBLC is a network of providers,
consumers, researchers, public health
professionals, community leaders, advocates, and other stakeholders whose
primary aim is to improve birth outcomes in their local communities. The
collaboration is guided by the principles
of community-based participatory research.106,107 The goal is to bring MCH
and non-MCH partners together on a
regular basis for networking and resource sharing. The HBLC provides a
forum for community voices to be heard
and creates a platform for civic engagement, grassroots advocacy, and social
and human capital development by
CLOSING GAP IN BIRTH OUTCOMES - Lu et al
facilitating MCH leadership development and community building.
ADDRESS SOCIAL AND
ECONOMIC INEQUITIES
Closing the Black-White gap in
birth outcomes also requires changing
social institutions and public policies
with the goals of reducing early life
disadvantages and cumulative allostatic
load over the life course.108 We believe
closing the education gap, reducing
poverty, supporting working mothers
and families, and undoing racism are
important in eliminating racial disparities in birth outcomes. This is a
new paradigm for MCH partners.
Maternal and child health advocates
are not exempt from addressing disparities outside traditional boundaries; it is
imperative that we understand how
cumulative social and economic inequities contribute to health disparities in
MCH.
Close the Education Gap
More than 50 years after Brown v
Board of Education, the Black-White
gap in education persists. Despite school
desegregation, today many of our
schools, particularly in inner cities,
remain separate and unequal. The
Black-White education gap actually
starts before children enter school. On
average, African American children enter kindergarten with substantial deficits
in reading and math skills, perhaps
reflecting early life disadvantages.109
The education gap widens between first
and twelfth grades.110 African American
children, particularly from low-income
families, are more likely to attend
schools with fewer resources, poorer
quality teachers and lower expectations.
The gap grows after school and during
summer months, as African American
children have fewer opportunities for
learning enrichment outside of
school.111 African American children
are also more likely to experience health
problems (eg, vision, hearing, oral
health, asthma) but less likely to receive
adequate health services for those problems.108 Because of housing and job
instabilities in the family, African American children are more than twice as
likely as White children to have
attended at least three different schools
by third grade.112 Both health problems
and residential mobility could create
stress and interfere with learning. As a
result of all these factors, African
American students are significantly less
likely to graduate from high school and
to complete college.103 Lower educational attainment predicts lower earnings (and less health insurance coverage
and access to health care, fewer resources, greater job strains and insecurity, and poorer housing and neighborhoods). Lower educational attainment
also predicts poorer reproductive health
and poorer pregnancy outcomes,3 possibly mediated through greater cumulative allostatic load over the life course.
The solutions to closing the BlackWhite gap in birth outcomes require
closing the education gap and are
neither easy nor cheap.108 Children
cannot learn well without a healthy
brain and so early childhood development must begin before birth, or even
conception. None of us are born ready
to parent and so parenting education
must also begin before the child’s birth.
Presently, most Head Start programs do
not begin until age 3 or 4. To narrow
the education gap in early life, children
from low-income households should be
offered optional full-day, year-round
early childhood programs starting as
early as six months of age and full-day,
year-round pre-school at ages 3 and 4.
These programs should be staffed with
professional teachers and nurses, and
provided curricula emphasizing literacy
and appropriate social and emotional
growth. Optimally they should attend K
through 12 schools with small class size,
good teachers, high expectations, standards, accountability, after-school and
summer programs, and full-service
Ethnicity & Disease, Volume 20, Winter 2010
school-community clinics. The costs of
adding these programs to all US schools
with at least 40% low-income children
is estimated at $156 billion a year, or
$12,500 per pupil.109 That is the level
of commitment our nation must make
to close the Black-White gap in education.
Reduce Poverty among African
American Families
A disproportionate number of African Americans live below the poverty
level, accounting for about one-quarter
of the US population in poverty in
2001.103 One in four (25%) Black
women are poor, a rate nearly three
times that for non-Hispanic White
women (9%). Nearly one in three
(30%) African American children live
in a poor household, a rate three times
that for non-Hispanic White children
(10%). The poverty rate is highest
among single-parent households headed
by African American women; one in
three (35%) such households are poor,
and more than half (58%) report an
annual income of less than $25,000.103
Poverty predicts poorer health,108 perhaps reflecting greater cumulative allostatic load over the life course and
resulting in increased biobehavioral
vulnerability during pregnancy.
Public policy can help reduce poverty among African American families.
First, raising the minimum wage, expanding EITC, strengthening collective
bargaining, and adopting pay equity
policies will substantially increase incomes for working families. Raising the
minimum wage by one dollar will
impact nearly 30% of working African
American women who work for minimum or low wages.113 Expanding EITC
may be more effective in moving
families over the poverty line than any
other government programs.114 An innovative proposal, the ‘‘Universal Unified Child Credit,’’ combines both
expanded EITC with child tax credits.115 Unions raise wages and benefits
of unionized workers by about 28%.116
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CLOSING GAP IN BIRTH OUTCOMES - Lu et al
Second, investing in a social safety net
of programs, such as food stamps,
Section 8 vouchers for housing and
Medicaid, will help poor African American families meet basic needs. In 2000,
low-income single mothers earned, on
average, about $8,000, but after the
EITC and other public assistance their
average income nearly doubled, to
about $16,000.117 Third, an economy
that delivers on full employment, living
wages, fair trade, job training and
retraining, and health insurance coverage will help reduce poverty among
African American families.117
Support Working Mothers and
Families
Most African American mothers
work. Two areas will serve as examples
of where public policy can better
support working mothers: parental leave
and child care. Leave policies give
working parents the right to take time
off from work without the risk of losing
their jobs. Before the 1993 Family and
Medical Leave Act (FMLA), the United
States had no national maternity (or
paternity) leave legislation,118 in contrast to most developed nations (most
with paid leave). While FMLA dramatically increased both maternity and
paternity leave coverage, it is not
universal. Part-time employees, employees in small businesses, and employees
with short job tenure are often not
covered or eligible. As a result, only
45% of parents working in the private
sector have guaranteed unpaid parental
leave through FMLA. African Americans have higher coverage under FMLA
because they are proportionately more
likely to work in the public sector and
for large establishments; nonetheless,
nearly 30% of working African Americans parents do not have guaranteed
leave. Women with leave coverage are
more likely to take leave and to take
longer leaves.118 FMLA is also limited
in that it provides only 12 weeks of
unpaid parental leave. Less than 5% of
parents working in the private sector
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have access to paid parental leave.118
This lack of paid leave is a barrier to
women’s taking leave or taking as much
leave as needed; many women face
substantial loss of income by taking an
unpaid leave.119 As a result, nearly a
third of women on maternity leave
returned to work in less than 6 weeks;
over 70% returned to work in less than
12 weeks.119
Clearly public policy can do more to
support working parents so they can
care for their newborn or sick child
without the risk of losing their jobs or
pay.118 Some have begun to call for
expanding parental leave coverage, extending the duration of leave allowed,
providing more opportunities for parents of young children to return to work
part time, and making provisions for
income replacement during leave.118
With respect to the latter, public
financing options include using: 1)
unemployment insurance, 2) temporary
disability insurance programs, 3) a new
social insurance program, and 4) a new
cash benefit program.118 In July 2004,
California became the first state to
provide paid leave for up to six weeks
for parents with a newborn or for
employees with an ill family member.
Small businesses (less than 50 employees) are exempt. The program is funded
from employee payroll tax. In contrast,
most European countries provide for
longer paid parental leaves largely
financed through social insurance programs.118
One of the most dramatic transformations in the American family over the
past 30 years has been the increased
labor force participation rates of
mothers with young children.118 The
majority (57%) of mothers with children aged 0 to 3 years work. This trend
is particularly striking for low-income
families with single parents. Prior to the
1996 Personal Responsibility and Work
Opportunity Reconciliation Act
(PRWORA), Aid to Families with
Dependent Children (AFDC) provided
cash assistance to low-income single
Ethnicity & Disease, Volume 20, Winter 2010
mothers to allow them to remain at
home and care for their children. The
Temporary Assistance for Needy Families now requires mothers to work or
seek employment or training as a
condition of receiving cash assistance.
When single mothers or both parents
are working, child care is needed. In
2001, 48% of African American children aged 0 to 2 years, 74% aged 3 to 6,
and 66% in grade school are in nonparental care; the majority in centerbased programs.120,121
Two major concerns of working
mothers are child care costs and quality.
While working families that pay for
child care spend, on average, about 9%
of their earnings on child care, that
burden is higher for low-income families (16% of earnings), and for singleparent low-income families (19% of
earnings).122 While low-income families
are more likely to receive help (eg,
relatives, government subsidies) for
child care, 40% of low-income families
that pay for child care spend, on
average, $1 of every $6 in earnings for
that care.122,123 And much of the
quality of child care available for young
children is mediocre or worse. Children
in lower-income families often receive
lower quality care than children in
higher-income families.118 Long-term
follow-up studies of low-income children randomly assigned to a treatment
group receiving high-quality child care
versus a control group without any
special services revealed lower rates of
crime, welfare dependency, and teen
pregnancy, and higher educational attainment, employment, and earnings
among those receiving high-quality
child care.118,124
Public policy can assist working
parents, particularly single mothers and
low-income families, so they can afford
high-quality child care.118 Presently,
child care for low-income families is
supported primarily through subsidies
to parents or private market providers.
While this approach increases parental
choice, it creates challenges in ensuring
CLOSING GAP IN BIRTH OUTCOMES - Lu et al
access and quality. One option is to
provide vouchers with a reimbursement
rate that increases with the developmental quality of child care purchased.
This would give parents an incentive to
seek higher quality child care and
providers an incentive to improve
quality. Public early education programs
like Head Start and Early Head Start
also need expansion. Head Start is
mostly a part-day, part-year program
for poor families, serving about 50% of
eligible children aged 3 or 4 years-old.
Early Head Start serves only a small
share of eligible children under 3 years
old. These high-quality programs need
to be expanded to serve more children
from birth to 5 years old and for more
hours to meet the full-day, year-round
needs of working families. Another
option is to expand prekindergarten
and other early education programs
delivered in community-based child
care programs, and to link prekindergarten funding to higher standards,
teacher qualifications, and curriculum
requirements. An Institute of Medicine
report estimates that expanding child
care subsidies through quality-related
vouchers for eligible children would cost
$54 billion, expanding and increasing
access to full-day, full-year Head Start
and Early Head Start would cost $25
billion, and expanding prekindergarten
and other early education programs
would cost $25 to $35 billion.118
Despite their high costs, we believe
these programs will pay great dividends
in the long run and pay for themselves
many times over.
Undo Racism
Increasing evidence suggests racism
may be the ‘‘cause of the cause’’ of
health disparities in the United States.
The experience of racial discrimination
in pregnancy or over the life course by
African American women is associated
w i t h i n c r e a s e d r is k o f V L B W
births.125,126 A greater Black-White
gap in infant mortality was found in
more racially segregated cities.127,128
Camara Jones proposed a theoretical
framework for understanding racism on
3 levels – internalized, personallymediated, and institutionalized racism
– and introduced an allegory about a
gardener with 2 flower boxes, with
either rich or poor soil, to illustrate
the differences in and remediation of
these.129 Institutionalized racism, or
differential access to the goods, services,
and opportunities of society by race, is
the soil – and this is the most fundamental level to address for change. Our
12-point plan is essentially about enriching the soil with better healthcare,
education, child care and other social
supports to grow healthier mothers and
babies.
What are the specific roles of MCH
professionals in undoing racism? Maternal and child health is a field
consisting of people from diverse backgrounds and disciplines, including researchers, service providers, public
health professionals, and community
advocates. Each has a role in undoing
racism. Researchers need to develop
better measures of racism, identify
causal pathways linking racism to health
disparities, design longitudinal studies
of both current racism and racism over
the life course and across generations,
and develop intervention studies to
address multiple levels of racism including institutionalized racism. Healthcare
providers and other service providers
need to critically examine their personal
attitudes and behaviors, and institutional practices and policies, to assure
all patients or clients, regardless of race
and ethnicity, receive equitable care.130
Public health professionals need to
make racism a leading public health
issue, including collecting data on
racism in population and community
health assessments, assuring equal access
to quality healthcare, monitoring for
discriminatory practices, and making
policies (or collaborating with other
public agencies to make policies) to
assure equal access to goods, services,
and opportunities vital to maternal and
Ethnicity & Disease, Volume 20, Winter 2010
child health. In all these efforts, community voices must be heard. They have
been telling us that racism is a main
cause of disparities in birth outcomes;
now the community must be included
as partners in collaborative efforts to
undo racism.
Many of our social institutions and
public policies create early life disadvantages and disproportionate allostatic
load on the health of African American
women over their lifespan. We cannot
eliminate racial disparities in birth outcomes without addressing racial disparities in education, healthcare, housing, employment, the criminal justice
system and the built environment.
While MCH advocates are not expected
to solve all these problems, we can do a
number of things to address social and
economic inequities. First, we need to
educate ourselves about disparities in
other domains of life and their impact
on maternal and child health. We need
to see how disparities in their fields
impact ours and to champion their
causes as much as we need them to
champion ours. Second, we need to
partner with people from other walks of
life who also address racial disparities.
They need to see how disparities in
MCH affect the disparities they address.
In too many of our meetings, we are
preaching only to the choir. We can
begin by inviting unusual partners from
other sectors, such as education, community development, city planning, and
the criminal justice system to our
meetings. Third, we need to join forces
with these non-MCH partners in advocacy. All these require transformative
leadership that brings people together to
see a common vision and work for a
common cause. The common vision is
the life course perspective; the common
cause – social justice.
CONCLUSIONS
We outlined a 12-point plan to close
the Black-White gap in birth outcomes
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using a life course approach. Collectively these points represent a new
approach to an old problem. They go
beyond prenatal care to address the
healthcare needs of African American
women over the life course. They go
beyond individual-level interventions
that are often short-lived (eg, during
pregnancy or a funding grant) to
address strengthening family and community systems that may have a
broader, more lasting impact on the
health of pregnant women, families, and
communities. And they go beyond the
biomedical model to address the social
and economic inequities that create
disproportionate allostatic load on African American women’s health.
Two more things are needed for real
change – a greater knowledge base and a
stronger political will.131 We need to
build on our knowledge base with not
only more research, but better research.
Current MCH research is limited by 3
major disconnects: disconnect between
the perinatal period and the rest of the
life course (longitudinal disconnect),
disconnect between the individual and
her environments (contextual disconnect), and disconnect across disciplines
and between academic and community
researchers (intellectual disconnect).
Longitudinal integration is needed to
better understand life course influences
on perinatal outcomes and perinatal
influences on life course outcomes. This
requires more longitudinal birth cohort
studies and databases linkages across the
lifespan. Contextual integration is
needed to better understand influences
of neighborhood and community characteristics on individual health and
behaviors, and to delineate how these
contextual factors become embedded in
pregnancy physiology and developmental biology (ie, how social inequality gets
under the skin). This requires the
development of better measures (eg,
for institutionalized racism) and methodologies for contextual analyses. Intellectual integration is needed to break
out of disciplinary and institutional silos
S2-72
and bridge the academic-community
divide that has limited our research.
This requires building infrastructure
(eg, training programs, research networks) to support transdisciplinary research and community-academic partnerships. Most importantly, we need
more praxis – the integration of knowledge and practice. Research cannot help
if it is not translated into effective
interventions. This requires a new
approach to designing intervention
studies and evaluating their impact from
multi-level, life-course perspectives. It
requires collaboration among researchers from diverse fields (eg, health,
education, housing, criminal justice)
and among funders to support largescale social experimentation using a
comprehensive, life-course approach.
We will not close the Black-White
gap in birth outcomes without political
will to do so. Political will is the ability
to command resources to make things
happen (ie, implement the 12 points).
There are several things we can do to
create political will. First, we need
evaluation research to demonstrate the
effectiveness and cost-benefit of these
broadened concepts of health care. The
impetus for expanding public coverage
of prenatal care in the late 1980’s came
largely from studies demonstrating costsavings in postnatal infant care with the
provision of prenatal care. Now we need
to make an equally compelling case for
the cost-benefit of interconception and
preconception care, with benefits measured in terms of immediate birth
outcomes and long-term health and
developmental outcomes, and cost savings accrued in the healthcare, education, criminal justice, welfare, and other
systems.
Second, we need to increase demand
for comprehensive women’s health care
before and between pregnancies and
over the life course. We must make the
case to the American public that
preconception care, interconception
care, and access to quality health care
over the lifespan are as important, if not
Ethnicity & Disease, Volume 20, Winter 2010
more than, as prenatal care is to the
health and wellbeing of mothers and
infants. We need to create this demand
not just among White middle-class
women (critical for creating political
will), but especially among African
American women.
Third, we need leadership. Currently there is growing political will to
support father involvement (eg, federal
Fatherhood Initiative) and systems integration (eg, federal Community Integrated Service System projects). Ideas
such as the One Hundred Acts are met
with great receptivity in communities
because they demonstrate what communities can do for themselves to
increase social support and social capital
for pregnant women and families.
Partisan politics aside, we can all agree
that father involvement, family-centered
care, and strong social capital are good
for the African American community,
or any community. What we need is
leadership to make it happen. Community- and faith-based organizations can
take the lead in creating reproductive
social capital. County and state governments can encourage service integration
by blending categorical funding streams.
Maternal and child health professionals
can play a leadership role in consensus
building – bringing people together to
see a common vision and to work on a
common cause.
Fourth, we need creativity in building linkages and partnerships. We need
linkages to on-going efforts to address
disparities in other domains of life, such
as broadening the vision of No Child
Left Behind to include a health component. We need to develop partners from
education, community development,
city planning, and the criminal justice
system. We need to make the case to
businesses and industries to support
more mother-friendly workplaces and
leave policies – in terms of reduced
medical costs, lower absenteeism, and a
more stable and productive workforce.
Lastly, we need to renew the public
discourse on health disparities in the
CLOSING GAP IN BIRTH OUTCOMES - Lu et al
terms of social justice. This is primarily
a moral issue; in what kind of America
do we want our children to grow up? An
America where a Black baby has twice
the chance of dying within the first year
of life as a White baby, three times the
chance of being born to a single mother,
three times the chance of growing up in
a poor household, twice the chance of
going without health insurance, half the
chance of completing college, and a life
expectancy 5.5 years shorter? Or an
America where all men and women are
created equal and are afforded equal
rights and equal opportunities, and
where we treat our fellow Americans as
we want to be treated, or we wish our
children to be treated?
Institutionalized racism is often
evident as inaction in the face of need.
Continuing to do the same old things
that do not work in the face of
persisting disparities in birth outcomes
perpetuates institutionalized racism. For
too long we have looked for a quick fix
to close the gap. Elimination of racial
disparities in birth outcomes is attainable if we make the life course, perhaps
intergenerational, social investments it
will take. The 12 points are a beginning.
The health of our nation tomorrow
depends on the choices we make today.
ACKNOWLEDGMENTS
Support for this work was provided in part
by the National Institute of Health Women’s Reproductive Health Career Development Fellowship #HD01281-03, the National Institute of Child Health and Development Community Child Health Network
#U01-HD044245, the Centers for Disease
Prevention and Health Promotion Division
of Reproductive Health, and the Los Angeles
Best Babies Collaborative, a program of First
5 LA. The opinions expressed in this paper
are the authors’ and do not necessarily reflect
the views or policies of the institutions with
which the authors are affiliated.
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